So far, Jakarta is the only province in Indonesia where no cases of stunting have been recorded. (Antara Photo/M. Agung Rajasa)

What Else Can Jokowi Do to Fight Stunting?


JULY 22, 2019

Jakarta. Indonesia's recently re-elected president, Joko "Jokowi" Widodo, outlined his visions for his new term last week. One of them emphasized plans to improve the country's human resource.

"Human resource development is Indonesia's key in the future, and its starting point is to ensure the health of pregnant women, infants, toddlers and school children. This is a golden age to create superior Indonesians for the future," Jokowi said in Bogor, West Java, last week.  

Up until this year, Indonesia is still among the five countries with the highest number of stunting cases in the world. The president said in his speech that he did not want to hear any more cases of stunting, malnutrition or high maternal and child mortality in the next five years.

The government is now left with a huge task. Indonesia is expected to receive a demographic bonus in 2030 when Indonesia's young population comes of age. By then, the productive age group is expected to dominate the population and help boost economic development. This demographic bonus will comprise Indonesians between 15 and 64 years old. They are predicted to make up 68 percent of the total population. Only 9 percent of the population will be people 65 years old or above.

However, this potential demographic bonus will be squandered if our most valuable resource, the children, continue to suffer from stunting.

Children are defined as stunted if their height-for-age is more than two standard deviations below the World Health Organization's child growth standards median. Its causes include inadequate daily food or nutritional intake since the baby is in the womb and up to the child's birth. Signs of stunting usually appear after a child is two years old.

Stunted children tend to experience difficulties in their studies compared to those with sufficient nutritional intake. They are also likely to experience slower physical and mental development, reduced productive capacity and poor health. They also face higher risks of developing non-communicable diseases at an earlier stage.

If stunting in Indonesia continues at its present rate, the World Bank estimated it could lead to a 2 to 3 percent loss in the national gross domestic product.

Several government programs have been devised to overcome Indonesia's stunting problem in the past five years. One of them is the Presidential Regulation No. 42/2013, the legal framework for the National Campaign for Nutrition Improvement Acceleration, in which 13 ministries work in collaboration to prevent stunting.

The government program to prevent stunting includes improving community nutrition through supplementary feeding programs to increase children's nutritional intake.

Efforts have also been made to improve sanitation quality in 250 villages in 60 districts and cities throughout the country, with priority targets in communities with a high stunting prevalence.

The government has also built more drinking water and sanitation infrastructure to improve the quality of human life throughout the country and stop the spread of stunting.

Some Success in Fight Against Stunting

Jokowi's first term as president saw some progress in the fight against stunting. According to a study by the Health Ministry in 2018, the prevalence of stunting in Indonesia fell by as much as 6.4 percent during Jokowi's presidency, from 37.2 percent in 2013 to 30.8 percent in 2018.

However, that rate of decline is still too slow by world standard. Worse still, high numbers of stunting are still found equally in rural and urban areas. So far, Jakarta is the only province where no cases have of stunting have been reported.

This is why Jokowi included fighting stunting as one of the most important promises of his new five-pronged vision. His vice president Ma'ruf Amin had also promised during the presidential campaign to reduce stunting by up to 10 percent in five years.

And yet, Jokowi has not actually revealed any specific, practical details in his plan to fight stunting. All that have been said – increasing nutrition, improving sanitation, etc. – are general prescriptions on the fight against stunting and have all been done before. 

To put it bluntly, new initiatives are required to fight stunting in Indonesia. 

First, pregnant mothers and children under the age of two need better access to key services. These include primary immunization, breastfeeding, dietary diversity, drinking water and sanitation, early childhood education, food insecurity measurements where they live and a birth certificate to make sure they do not get left behind in the country's health system. Unfortunately, the convergence of these critical services is still low in Indonesia.

All these services need to be strengthened and so is the convergence of national, regional and community programs to fight stunting. The government's previous anti-stunting program in 2018 was rolled out in 100 districts with high stunting rates and had shown good progress. The second Jokowi administration needs to scale up its coverage to all 514 districts and cities with high stunting rates in Indonesia.

Second, the government also needs to strengthen coordination between central and local governments. Decentralization has brought in more local input and faster decision-making, but at times it can also scupper national policies. 

Indonesia needs a simple but integrated data system linking local and central governments to accelerate the planning of interventions, close the gap between regions, maximize multi-sectoral coordination and improve monitoring and evaluation.

An integrated data system starting at the grassroots level will help map malnutrition and ensure stunting interventions are effective, efficient and well-targeted. It will minimize the number of underreported cases as well.

Last, the government cannot do all of this on its own. One out of four children grows up stunted even among Indonesia's top wealth quintile. This means that people's behaviors need to change as well, even among those who have high purchasing power and can afford nutritious diets.

Parents need to make the right decisions to optimize nutrition for their children. Public awareness campaigns on stunting need to be supercharged. Some of the existing safety nets can be used as a platform to improve knowledge and change behaviors. 

Stunting has a significant impact on all aspects of development, from human resource to economic growth. Investing more money and effort to reduce stunting now will result in a very handsome payoff in the not too distant future. It will not be at a cost to the economy; it will be an investment for Indonesia's future.

Nadhira Nuraini Afifa is a physician from Universitas Indonesia who is currently completing her master's degree in public health at Harvard University.